Bilateral Lower Abdominal Free Flaps for Unilateral Breast Reconstruction

When the reconstructive requirements for one breast exceed the volume of available abdominal tissue that can be reliably transported on one vascular pedicle, the use of bilateral abdominal flaps may be a reasonable alternative. These authors presented their experience with the use of bilateral lower abdominal free flaps for unilateral breast reconstruction.

A retrospective analysis of consecutive microsurgical breast reconstruction was performed between 1994 and 2003. Twenty-two patients were identified in whom two free flaps were utilized simultaneously to reconstruct a single breast.

Patient ages ranged from 30.8 to 70.8 years (average: 46.8 years). Average follow-up was 3.4 years (range: 0.3 to 10.1 years). The rationale for use of two free flaps included: large breast size (16 cases), midline abdominal scar (10), small abdominal soft-tissue volume (8). Eleven breasts were reconstructed immediately following mastectomy, and 11 were delayed. 4/22 patients received preoperative and 6/22 postoperative radiation therapy. Forty-four flaps were utilized in 22 patients: superficial inferior epigastric flap (SIEF) = 16, TRAM = 12, muscle-sparing TRAM (MTRAM) = 10, deep inferior epigastric perforator flap (DIEP) = 6. Flaps were combined as follows: TRAM/TRAM = 3, TRAM/SIEF = 3, MTRAM/DIEP = 4, MTRAM/SIEF = 3, DIEP/SIEF = 1, SIEF/SIEF = 5, DIEP/DIEP = 3. Operative time ranged from 7 to 13 hr (average: 8.7 hr). There were no flap losses. 5/22 patients experienced major complications: re-operation for arterial thrombosis (n = 1) and arterial spasm (n = 1); native mastectomy skin loss (n = 1) in a patient with preoperative RT; fat necrosis (n = 2) requiring re-operation following operative RT to DIEP and SIEF flaps. There were no abdominal hernias. Abdominal bulge occurred in 3/7 patients (all free TRAMs having onlay mesh repair); 5/5 inlay mesh repairs resulted in no abdominal bulge. Symmetrical volumetric breast reconstruction was achieved in 17/22 patients at the initial reconstructive setting; 5/22 patients underwent secondary contralateral mastopexy or reduction mammaplasty to achieve volumetric symmetry.

This study demonstrated that double free flaps for unilateral breast reconstruction can be safely conducted. The risk of abdominal bulge appeared to be related to resection of the rectus abdominis muscle. In this series, inlay mesh repair of the fascia was found to be superior to onlay mesh repair in preventing this complication. Advantages of the double free flap technique lie in the ability to duplicate the opposite breast volume and to achieve symmetry, despite the presence of abdominal scars and/or paucity of lower abdominal soft tissue.